Consider these exercises for chronic musculoskeletal conditions
Exercise interventions reduce pain and improve function in knee/hip OA, chronic low back pain, shoulder pain, Achilles tendinopathy, and lateral epicondylitis.
PRACTICE RECOMMENDATIONS
› Consider quadriceps strengthening for knee osteoarthritis with an initial period of supervision, which can provide greater pain relief than nonspecific, unsupervised lower limb exercises. B
› Consider a generalized exercise program for subacromial impingement syndrome, to relieve shoulder pain and improve function, range of motion, and strength. A
› Bear in mind that the Alfredson protocol for Achilles tendinopathy has yielded improvement in pain and function for up to 5 years, although other exercise regimens have also proven initially effective. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
From The Journal of Family Practice | 2018;67(9):534-538,540-543.
Appropriate exercise prescriptions for patients with knee or hip OA should focus on low-impact activities that can improve strength, flexibility, and function (FIGURE 1). A typical regimen would be 30 or more cumulative minutes daily of stationary cycling, water-based exercises, or strength training, 3 to 5 days per week. Individualize workout intensity for each patient, emphasizing that high-intensity, low-impact effort may yield greater strength gains and take less time to perform.11 A high-intensity exercise prescription focusing on quadriceps, hip, and core strengthening may consist of 3 sets of 8 repetitions with resistance set at 40% of the maximum resistance against which the patient can perform 1 repetition.7
Barriers to exercise in knee and hip OA include negative patient and provider perspectives on exercise and patients’ fear that increased activity may actually worsen OA.12 Depending on a patient’s personal preferences, ways to overcome these barriers and encourage adherence might be supervised exercises in an individual or group setting or audiotapes or videos of recommended exercises.10
Chronic low back pain
Chronic low back pain (LBP) is a large socioeconomic burden in the United States, with upward of $100 billion per year accounted for in health care costs and decreased worker productivity.13 The etiology of chronic LBP can be multifactorial and due to any of several conditions such as degenerative disc disease, spinal stenosis, spondylolisthesis, and facet arthropathy. Treatment is difficult, given that many common interventions—medications, massage, manipulation—have limited efficacy.14 However, for patients with nonspecific chronic LBP, exercise is an effective intervention for reducing pain and improving physical function.15
An effective approach is to design an exercise regimen for the individual by type, duration, and frequency of activity, administered under supervision to encourage adherence.16 Appropriate exercises emphasize resistance, strength training, and core stabilization, often focusing on whole body and trunk motion (FIGURE 2).17
Although yoga or Pilates classes may have a small effect on function, no high-quality evidence exists for their superiority to other forms of exercise.18,19 Back School, a therapeutic program that includes education on anatomy and biomechanics, optimal posture, ergonomics, and back exercises, has limited, low-quality evidence for treatment comparisons.20 Aerobic exercise, including treadmill, elliptical, or cycling exercises or walking outdoors can reduce pain and improve physical and psychologic functioning.21
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